Brain death Present status YDS

Dr (Brig) YD SinghMBBS, MD, FIACM, DIT

Professor (Internal Medicine)SKN Medical College & Gen Hospital

Pune 411 041

Brain DeathBrain Death Death: An IntroductionDeath: An Introduction

Genesis of Brain Death concept ?Genesis of Brain Death concept ? DeathDeath definition under Indian Laws definition under Indian Laws What is brain death? What is brain death?

Scene in USAScene in USA Scene in IndiaScene in India

Causes of Brain DeathCauses of Brain Death Brain Death DiagnosisBrain Death Diagnosis Other Related TermsOther Related Terms

Permanent Vegetative StatePermanent Vegetative State Locked in SyndromeLocked in Syndrome ComaComa

9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh

Normal Brain AnatomyNormal Brain Anatomy


Cerebral CortexCerebral Cortex

Brain StemBrain Stem

Reticular Reticular Activating Activating

SystemSystem

Receives multipleReceives multiplesensory inputssensory inputs

&&MediatesMediates

ConsciousnessConsciousness(wakefulness)(wakefulness)

Two Dimensions of Two Dimensions of ConsciousnessConsciousness


Cerebral Cortex: FunctionCerebral Cortex: Function


CognitionCognition Voluntary MovementVoluntary Movement SensationSensation

Brain Stem : FunctionsBrain Stem : Functions


MidbrainMidbrain

Cranial Nerve IIICranial Nerve III

Pupillary FunctionPupillary Function

Eye MovementEye Movement



PonsPons

Cranial Nerve IV, V, VICranial Nerve IV, V, VI

Conjugate Eye MovementConjugate Eye Movement

Corneal ReflexCorneal Reflex



MedullaMedulla

Cranial Nerve IX, XCranial Nerve IX, X

Pharyngeal (Gag) ReflexPharyngeal (Gag) Reflex

Tracheal (Cough) ReflexTracheal (Cough) Reflex

RespirationRespiration

Death : DefinitionDeath : Definition

Thanatology Thanatology Branch of science dealing with study of deathBranch of science dealing with study of death

Death is the complete and irreversible Death is the complete and irreversible stoppage of stoppage of CirculationCirculation RespirationRespiration Brain function (Tripod of life)Brain function (Tripod of life)

As long as oxygenated blood reaches brain stem, Life As long as oxygenated blood reaches brain stem, Life exists ….exists ….

Mechanical Ventilator use in ICUMechanical Ventilator use in ICU Brought concept of “Brain Death”Brought concept of “Brain Death”


Brain Death : USABrain Death : USA

Uniform Determination of Death Act 1981Uniform Determination of Death Act 1981 An individual who has sustained eitherAn individual who has sustained either

Irreversible cessation of circulatory & respiratory Irreversible cessation of circulatory & respiratory functions, or functions, or

Irreversible cessation of all functions of the entire Irreversible cessation of all functions of the entire brain, including the brain stem, is dead. brain, including the brain stem, is dead.

A determination of death must be made with A determination of death must be made with accepted medical standardsaccepted medical standards..

The Act did not define the The Act did not define the accepted medical accepted medical standardsstandards


Brain Death : USABrain Death : USA

The American Academy of Neurology (1995)The American Academy of Neurology (1995) Published practice parameter to delineate Published practice parameter to delineate

medical standards for the determination of medical standards for the determination of brain death (These are accepted world wide)brain death (These are accepted world wide)

3 clinical findings necessary to confirm 3 clinical findings necessary to confirm irreversible cessation of all functions of the irreversible cessation of all functions of the entire brain, including brain stementire brain, including brain stem Coma (with a known cause)Coma (with a known cause) Absence of brainstem reflexesAbsence of brainstem reflexes ApnoeaApnoea


Death Definition : Indian LawsDeath Definition : Indian Laws

Registration of Births & Deaths Act 1969Registration of Births & Deaths Act 1969 Defines death as permanent disappearance of Defines death as permanent disappearance of

all evidence of life at any time after live-birth all evidence of life at any time after live-birth has taken place. {Section 2 (1)(b) }has taken place. {Section 2 (1)(b) }

Transplantation of Human Organs Act 1994Transplantation of Human Organs Act 1994 ““Brain-Stem death" Means the stage at which Brain-Stem death" Means the stage at which

all functions of the brain-stem have all functions of the brain-stem have permanently and irreversibly ceased and is so permanently and irreversibly ceased and is so certified under sub-section (6) of section 3certified under sub-section (6) of section 3


Brain Death : Indian LawsBrain Death : Indian Laws

Transplantation of Human Organs act, 1994Transplantation of Human Organs act, 1994 ““Deceased person" Deceased person"

Means a person in whom permanent disappearance Means a person in whom permanent disappearance of all evidence of life occurs, by reason of brain-stem of all evidence of life occurs, by reason of brain-stem death or in a cardiopulmonary sense, at any time death or in a cardiopulmonary sense, at any time after live birth has taken place { Section 2(e) }after live birth has taken place { Section 2(e) }


Brain Death : IndiaBrain Death : India

Transplantation of Human Organs act, 1994Transplantation of Human Organs act, 1994 Brain death needs to be certified by a board of Brain death needs to be certified by a board of

doctors consisting of :doctors consisting of : Registered Medical Practitioner (RMP) in charge of Registered Medical Practitioner (RMP) in charge of

hospital where brain death has occurredhospital where brain death has occurred An independent RMP – a specialistAn independent RMP – a specialist A Neurologist / Neurosurgeon nominated by panelA Neurologist / Neurosurgeon nominated by panel RMP treating the patientRMP treating the patient

The patient must be examined by team of The patient must be examined by team of doctors at least twice with a reasonable gap of doctors at least twice with a reasonable gap of time in between (at least 6 hours)time in between (at least 6 hours)


Brain Death : IndiaBrain Death : India

Transplantation of Human Organs act, 1994Transplantation of Human Organs act, 1994 Highlights:Highlights:

Statutary sanction to the Brain Death Statutary sanction to the Brain Death ConceptConcept

Regulation of Removal, Storage and Regulation of Removal, Storage and Transplantation of human organs for Transplantation of human organs for therapeutic purposestherapeutic purposes

Commercial dealings in human organs Commercial dealings in human organs preventedprevented


Causes: Brain DeathCauses: Brain Death


NormalNormal Cerebral AnoxiaCerebral Anoxia



NormalNormalCerebral Cerebral

HaemorrhageHaemorrhage



NormalNormal Cerebral TraumaCerebral Trauma

Brain Death : MechanismBrain Death : Mechanism


Neuronal Injury

Decreased Intracranial Blood Flow

Neuronal Swelling

Increased Intracranial Pressure

ICP > MAP is incompatible

with life

Brain Death: DiagnosisBrain Death: Diagnosis

04 Steps to diagnosis04 Steps to diagnosis

(1) Clinical Evaluation (Prerequisites)(1) Clinical Evaluation (Prerequisites) Establish Known Irreversible Cause of ComaEstablish Known Irreversible Cause of Coma Exclusion of Potentially Reversible ConditionsExclusion of Potentially Reversible Conditions

Drug Intoxication or PoisoningDrug Intoxication or Poisoning Electrolyte or Acid-Base ImbalanceElectrolyte or Acid-Base Imbalance Endocrine DisturbancesEndocrine Disturbances

Achieve Body temperature > 36° CAchieve Body temperature > 36° C Achieve Normal Systolic BP ( > 100 mm Hg)Achieve Normal Systolic BP ( > 100 mm Hg)


Brain Death: DiagnosisBrain Death: Diagnosis

04 Steps to diagnosis04 Steps to diagnosis (2) Clinical Evaluation (Neuro assessment)(2) Clinical Evaluation (Neuro assessment)

Establish ComaEstablish Coma Establish Absence of Brain Stem ReflexesEstablish Absence of Brain Stem Reflexes Establish ApnoeaEstablish Apnoea

Absence of Respiration driveAbsence of Respiration drive (3) Ancillary Tests(3) Ancillary Tests (4) Documentation(4) Documentation

Time of death is the time the arterial PaCO2 Time of death is the time the arterial PaCO2 reached the target value ORreached the target value OR

When ancillary test officially interpretedWhen ancillary test officially interpreted


Brain DeathBrain DeathNeurologic ExaminationNeurologic Examination

COMACOMA

Establish No response to noxious stimulusEstablish No response to noxious stimulus Nail Bed pressureNail Bed pressure Sternal RubSternal Rub Supra Orbital Ridge PressureSupra Orbital Ridge Pressure



Absent Brain Stem ReflexesAbsent Brain Stem Reflexes Pupillary Reflex (absent)Pupillary Reflex (absent) Eye MovementsEye Movements

Occulo-Cephalic ( Dolls Eye Movements)Occulo-Cephalic ( Dolls Eye Movements) Occulo-Vestibular (Cold Caloric test)Occulo-Vestibular (Cold Caloric test)

Facial Sensation and Motor ResponseFacial Sensation and Motor Response Pharyngeal (Gag) Reflex absentPharyngeal (Gag) Reflex absent Tracheal (Cough) Reflex AbsentTracheal (Cough) Reflex Absent




Pupils dilated with no constriction to bright lightPupils dilated with no constriction to bright light

Brain DeathBrain DeathNeurologic ExaminationNeurologic ExaminationOcculo Cephalic ResponseOcculo Cephalic Response

(No Dolls Eye Movements)(No Dolls Eye Movements)




Occulo-Vestibular ResponseOcculo-Vestibular Response

““Cold Caloric Testing”Cold Caloric Testing”

Normal Response in ComaNormal Response in Coma

No Response in Brain Stem DeathNo Response in Brain Stem Death



Facial Sensations & Motor ResponseFacial Sensations & Motor Response

• Absent Corneal ReflexAbsent Corneal Reflex

• Absent Jaw reflexAbsent Jaw reflex

• No response toNo response to Supraorbital OrSupraorbital Or Temporo-MandibularTemporo-Mandibular PressurePressure

Brain Death : Apnoea TestBrain Death : Apnoea Test

Pre-requisitesPre-requisites Body Temperature > 36° CBody Temperature > 36° C Systolic Blood Pressure ≥ 100 mm HgSystolic Blood Pressure ≥ 100 mm Hg Normal Electrolytes profileNormal Electrolytes profile Normal PaCO2 (35-45 mm Hg)Normal PaCO2 (35-45 mm Hg)

Pre-OxygenationPre-Oxygenation 100% Oxygen via Tracheal Cannula for 10 min100% Oxygen via Tracheal Cannula for 10 min Achieve PaO2 = 200 mm HgAchieve PaO2 = 200 mm Hg

Monitor PaO2 with pulse oximetryMonitor PaO2 with pulse oximetry


Brain Death : Apnoea TestBrain Death : Apnoea Test

Reduce Ventilation frequency to 10/minReduce Ventilation frequency to 10/min Reduce PEEP to 5 Cm H2OReduce PEEP to 5 Cm H2O Take 1Take 1stst Blood sample for Blood Gas analysis Blood sample for Blood Gas analysis Disconnect VentilatorDisconnect Ventilator Deliver 100% O2 by catheter through ET tubeDeliver 100% O2 by catheter through ET tube

@ 6 L/min@ 6 L/min

Observe for Respiratory Movement Observe for Respiratory Movement Atleast for 8 – 10 minAtleast for 8 – 10 min


Brain Death : Apnoea TestBrain Death : Apnoea Test Discontinue TestingDiscontinue Testing

If BP drops to < 90 mm HgIf BP drops to < 90 mm Hg PaO2 to 85% by pulse Oxymetry for 30 SecPaO2 to 85% by pulse Oxymetry for 30 Sec

If no respiratory drive observed after 08 minIf no respiratory drive observed after 08 min Take next Blood sample for Blood gas studiesTake next Blood sample for Blood gas studies

If respiratory movements are absent & arterial PaCO2 is If respiratory movements are absent & arterial PaCO2 is 60 mm Hg OR60 mm Hg OR 20 mm Hg over a baseline normal PaCO220 mm Hg over a baseline normal PaCO2

The Apnea test result is POSITIVEThe Apnea test result is POSITIVESupports the clinical diagnosis of brain deathSupports the clinical diagnosis of brain death


Brain DeathBrain DeathAncillary Confirmatory TestingAncillary Confirmatory Testing


Recommended when Recommended when Proximate cause of coma is not known or Proximate cause of coma is not known or When confounding clinical conditions limit When confounding clinical conditions limit

clinical examinationclinical examination

EEGEEG Cerebral AngiographyCerebral Angiography PET : Glucose Metabolic StudiesPET : Glucose Metabolic Studies Dynamic Nuclear ScanDynamic Nuclear Scan Somato-Sensory Evoked PotentialSomato-Sensory Evoked Potential

Brain DeathBrain DeathConfirmatory TestingConfirmatory Testing


Electro-Cerebral SilenceElectro-Cerebral SilenceNormalNormal

EEGEEG

Brain DeathBrain DeathConfirmatory TestingConfirmatory Testing


No Intra- Cranial FlowNo Intra- Cranial FlowNormalNormal

Cerebral AngiographyCerebral Angiography

PETPETGlucose Metabolism StudiesGlucose Metabolism Studies


““Hollow-skull sign” Hollow-skull sign” of brain deathof brain death

Cerebral metabolism Cerebral metabolism globally reduced ~50% globally reduced ~50%

NormalNormal

Nature Rev Neurosci 2005;6:899-909

Dynamic Nuclear Brain Scan Dynamic Nuclear Brain Scan


““Hollow-skull sign” of brain deathHollow-skull sign” of brain death

NEJM 2001;344:1215-1221

Conditions Distinct fromConditions Distinct fromBrain DeathBrain Death

ComaComa

Persistent Vegetative StatePersistent Vegetative State

Locked in SyndromeLocked in Syndrome


ComaComa

It is a sleeplike state from which patient It is a sleeplike state from which patient cannot be arousedcannot be aroused It is sleep like becauseIt is sleep like because

Eyes remain closedEyes remain closed Patient is NOT aroused even by painful stimuliPatient is NOT aroused even by painful stimuli

We can simplify Coma by saying:We can simplify Coma by saying: A state lacking Wakefulness and AwarenessA state lacking Wakefulness and Awareness


Persistent Vegetative statePersistent Vegetative state

Patient out of Coma and appears awakePatient out of Coma and appears awake Follows Normal Sleep-Wake CyclesFollows Normal Sleep-Wake Cycles

No Response to Environmental StimuliNo Response to Environmental Stimuli Not Aware of surroundingsNot Aware of surroundings

Preservation of Brain Stem FunctionPreservation of Brain Stem Function Cause :Cause :

Diffuse Brain InjuryDiffuse Brain Injury


Persistent Vegetative statePersistent Vegetative state


Aruna Ramachandra ShanbagAruna Ramachandra ShanbagMumbaiMumbai

Locked in SyndromeLocked in Syndrome


Ventral Pontine Infarct

Complete ParalysisComplete Paralysis

Consciousness isConsciousness is Preserved Preserved

Preserved EyePreserved Eye MovementMovement

Brain DeathBrain DeathConclusionsConclusions

In the U.S., Brain death is considered In the U.S., Brain death is considered death for all purposesdeath for all purposes

In India Brain death is defined in Organ In India Brain death is defined in Organ transplantation act onlytransplantation act only It is Debatable if Brain Death applicable for It is Debatable if Brain Death applicable for

non organ donation?non organ donation?

We need to have Uniform Declaration of We need to have Uniform Declaration of Death legislation like US to settle the Death legislation like US to settle the issueissue


Brain DeathBrain DeathConclusionsConclusions

PVS Patient is not deadPVS Patient is not dead In a state of wakefulness In a state of wakefulness

without awarenesswithout awareness

Ancillary tests (EEG, Ancillary tests (EEG, PET) can help PET) can help distinguish Coma, PVS distinguish Coma, PVS & Locked-in state from & Locked-in state from Brain DeathBrain Death


Brain Death : Present StatusBrain Death : Present Status

Hippocrates said this long agoHippocrates said this long ago

(The Hippocratic Corpus)(The Hippocratic Corpus)

““First I will define what I conceive medicine to First I will define what I conceive medicine to be. In general terms, it is to do away with be. In general terms, it is to do away with the sufferings of the sick, to lessen the the sufferings of the sick, to lessen the

violence of their diseases, and to refuse to violence of their diseases, and to refuse to treat those who are overmastered by their treat those who are overmastered by their

disease, realizing that in such cases disease, realizing that in such cases medicine is powerless”. medicine is powerless”.


Thanks !!Thanks !!


Brain death Present status YDS

Health & Medicine

Transcript of Brain death Present status YDS